AMA Journal of Ethics^®

Abstract

Members of the AMA Opioid Task Force include the American Medical Association, the American Osteopathic Association, 25 specialty and state medical societies, and the American Dental Association. In 2015, the task force issued 6 recommendations focused on specific actions to help reverse the nation’s opioid epidemic. Clinicians have demonstrated progress in each of these areas, and, while much work remains, making good policy will be key to motivating continued progress. Recommendations adopted in 2019 focus on tangible actions policymakers can take to help end the epidemic. This article offers an overview of task force recommendations.

Professional Responsibility in Opioid Epidemic Responses

The American Medical Association (AMA) Opioid Task Force convened in 2014 to coordinate organized medicine’s response to the growing national epidemic of opioid-related overdose deaths and to amplify effective solutions and best practices. Members of the task force include the American Medical Association, the American Osteopathic Association, 25 specialty and state medical societies, and the American Dental Association.¹

The task force first recognized that to reverse this epidemic in the United States, clinicians must take tangible steps that have a measurable impact on improving patients’ access to evidence-based care and reducing opioid-related harm. These steps include emphasizing the need for judicious prescribing when clinically appropriate; integrating prescription drug monitoring programs (PDMPs) to track controlled substance prescriptions statewide and provide timely information about prescribing and patient behaviors; making appropriate referrals and promoting access to care for patients with substance use disorders; and other steps needed to reduce opioid-related harm. The task force issued 6 recommendations focused on the following specific actions that physicians can take:¹

1. Register for and use state PDMPs;
2. Make sure to have “education and training on effective, evidence-based treatment” for substance use disorder and pain;
3. “Support … comprehensive care for patients in pain and those with substance use disorder”;
4. Reduce stigma by providing comprehensive care to patients with pain and patients with substance use disorder, who deserve compassion, not judgment;
5. “Expand access to naloxone in the community and through co-prescribing”; and
6. Encourage “safe storage and disposal of opioids and all medications.”

Recommendations’ Influence

Since issuing these recommendations, the AMA has released 3 annual reports on actions clinicians have taken.^2,3,4 The most recent AMA Opioid Task Force progress report found that clinicians are taking action,⁴ and some reports suggest that prescription opioid-related mortality might be leveling off.⁵ Yet, the number of deaths from heroin and illicitly manufactured fentanyl and fentanyl analogs are at historic levels.^6,7,8 Key findings include the following:

• Decrease in opioid prescribing. Opioid prescriptions decreased 33% between 2013 and 2018, including a 12.4% decrease between 2017 and 2018.⁹
• Increase in PDMP use. Clinicians utilized state PDMPs more than 460 million times in 2018—an increase of 167 million queries from 2017 and 390 million queries from 2014.¹⁰
• Increase in education resource use. Health care professionals completed continuing education (CE) courses and accessed and reviewed education and training resources—including those devoted to opioid prescribing, pain management, opioid use and substance use disorder treatment, and related topics—more than 700 000 times in 2018, which represents an increase of 150 000 from 2017, according to an AMA survey and responses from 51 state and specialty society representatives (unpublished data, 2019). Additionally, the AMA Ed Hub™ hosts a content page devoted exclusively to opioids and pain management, which has a comprehensive list of CE activities sorted by topic.¹¹
• Increase in number of physicians certified to treat opioid use disorder. More than 85 000 physicians and a growing number of nurse practitioners and physician assistants are now certified to treat patients in-office with buprenorphine. This is an increase of more than 28 000 from 2016.¹² Because of advocacy by the AMA and state and specialty societies, more than 15 states have supported legislation to remove prior authorization for medications to treat opioid use disorder.¹³
• Increase in naloxone coprescribing. Nearly 600 000 naloxone prescriptions were dispensed in 2018. This is a more than fourfold increase from 136 000 dispensed in 2016.⁹

Although clinicians must follow the 6 Task Force recommendations in order for these positive trends to continue, continuation of these trends alone will not end the opioid epidemic in the United States. With more people dying each year, government and organizational policy is needed to protect patients’ access to evidence-based care for pain and opioid use disorder.

Policy Innovations Needed

In 2019, new task force recommendations were issued that call on policymakers and all relevant stakeholders to eliminate barriers to evidence-based treatment by taking the following steps¹⁴:

1. Remove prior authorization, step therapy (ie, fail-first processes requiring patients to try one or more medications specified by the insurance company, typically generic or lower-cost medicines), and “other inappropriate administrative burdens or barriers” that deny care or delay access to medications for addiction treatment for opioid use disorder approved by the US Food and Drug Administration.
2. “Support assessment, referral and treatment for co-occurring mental health disorders as well as enforce state and federal laws that require insurance parity for mental health and substance use disorders.”
3. “Remove administrative and other barriers to comprehensive, multimodal, multidisciplinary pain care and rehabilitation programs.”
4. “Support maternal and child health by increasing access to evidence-based treatment, preserving families and ensuring that policies are nonpunitive.”
5. Support civil and criminal justice system reforms “that help ensure access to high quality, evidence-based care for opioid use disorder,” including medications for addiction treatment.

In response to these recommendations, all 50 states and the District of Columbia have adopted policies to increase access to naloxone.¹⁵ A few states, such as Pennsylvania and Colorado, have also stepped up enforcement of mental health and substance use disorder parity requirements.¹⁵ At the federal level, Medicare has established new monthly payments for office-based opioid use disorder treatment and weekly payments for opioid treatment programs.¹⁶ A federal task force has also recommended sweeping changes to improve pain management policies and practices.¹⁷

Next Steps

Clinical- and policy-level improvements have been critical to saving lives, but more must be done to end the overdose epidemic in the United States. All barriers to and delays in receiving treatment must be eliminated. Payers, pharmacy benefit managers, and pharmacy chains must revise policies and practices that restrict patients’ access to opioid therapy or evidence-based care for pain or substance use disorders. Clinicians must continue to demonstrate leadership to make critical progress in eliminating overdose deaths. The AMA Opioid Task Force recommendations and a recent national roadmap report published by the AMA and Manatt Health¹⁵ are in alignment regarding policies and practices that can motivate desperately needed improvements to patient and community health outcomes.